Clinical handover within the emergency care pathway and the potential risks of clinical handover failure (ECHO) : primary research

Background and objectives: Handover and communication failures are a recognised threat to patient safety. Handover in emergency care is a particularly vulnerable activity owing to the high-risk context and overcrowded conditions. In addition, handover frequently takes place across the boundaries of organisations that have different goals and motivations, and that exhibit different local cultures and behaviours. This study aimed to explore the risks associated with handover failure in the emergency care pathway, and to identify organisational factors that impact on the quality of handover. Methods: Three NHS emergency care pathways were studied. The study used a qualitative design. Risks were explored in nine focus group-based risk analysis sessions using failure mode and effects analysis (FMEA). A total of 270 handovers between ambulance and the emergency department (ED), and the ED and acute medicine were audio-recorded, transcribed and analysed using conversation analysis. Organisational factors were explored through thematic analysis of semistructured interviews with a purposive convenience sample of 39 staff across the three pathways. Results: Handover can serve different functions, such as management of capacity and demand, transfer of responsibility and delegation of aspects of care, communication of different types of information, and the prioritisation of patients or highlighting of specific aspects of their care. Many of the identified handover failure modes are linked causally to capacity and patient flow issues. Across the sites, resuscitation handovers lasted between 38 seconds and 4 minutes, handovers for patients with major injuries lasted between 30 seconds and 6 minutes, and referrals to acute medicine lasted between 1 minute and approximately 7 minutes. Only between 1.5% and 5% of handover communication content related to the communication of social issues. Interview participants described a range of tensions inherent in handover that require dynamic trade-offs. These are related to documentation, the verbal communication, the transfer of responsibility and the different goals and motivations that a handover may serve. Participants also described the management of flow of patients and of information across organisational boundaries as one of the most important factors influencing the quality of handover. This includes management of patient flows in and out of departments, the influence of time-related performance targets, and the collaboration between organisations and departments. The two themes are related. The management of patient flow influences the way trade-offs around inner tensions are made, and, on the other hand, one of the goals of handover is ensuring adequate management of patient flows. Conclusions: The research findings suggest that handover should be understood as a sociotechnical activity embedded in clinical and organisational practice. Capacity, patient flow and national targets, and the quality of handover are intricately related, and should be addressed together. Improvement efforts should focus on providing practitioners with flexibility to make trade-offs in order to resolve tensions inherent in handover. Collaborative holistic system analysis and greater cultural awareness and collaboration across organisations should be pursued

Revealing design complexity: Lessons from the Open University

Design is an inherently complex activity. Design thinking is cognitively complex and design practice is contextually complex. This has implications for university-level design education which has traditionally displayed clear distinctions between the full-time and part-time undergraduate sectors, particularly in their teaching and learning strategies. However, a number of pressures and trends are evident which suggest that these two sectors are moving closer together. One of the drivers in this phenomenon is the need for students to be exposed to realistic levels of design complexity. This paper examines complexity in design and draws some significant parallels between modern design practice in general and the production of a new undergraduate course at the Open University. Both are used to illuminate design complexity. The paper suggests that some of the tools, techniques and approaches of part-time, undergraduate, distance design education might usefully be exploited in more traditional, full-time course models

Characterisation and expression of SPLUNC2, the human orthologue of rodent parotid secretory protein

We recently described the Palate Lung Nasal Clone (PLUNC) family of proteins as an extended group of proteins expressed in the upper airways, nose and mouth. Little is known about these proteins, but they are secreted into the airway and nasal lining fluids and saliva where, due to their structural similarity with lipopolysaccharide-binding protein and bactericidal/permeability-increasing protein, they may play a role in the innate immune defence. We now describe the generation and characterisation of novel affinity-purified antibodies to SPLUNC2, and use them to determine the expression of this, the major salivary gland PLUNC. Western blotting showed that the antibodies identified a number of distinct protein bands in saliva, whilst immunohistochemical analysis demonstrated protein expression in serous cells of the major salivary glands and in the ductal lumens as well as in cells of minor mucosal glands. Antibodies directed against distinct epitopes of the protein yielded different staining patterns in both minor and major salivary glands. Using RT-PCR of tissues from the oral cavity, coupled with EST analysis, we showed that the gene undergoes alternative splicing using two 5' non-coding exons, suggesting that the gene is regulated by alternative promoters. Comprehensive RACE analysis using salivary gland RNA as template failed to identify any additional exons. Analysis of saliva showed that SPLUNC2 is subject to N-glycosylation. Thus, our study shows that multiple SPLUNC2 isoforms are found in the oral cavity and suggest that these proteins may be differentially regulated in distinct tissues where they may function in the innate immune response

Defining Ecological Drought for the Twenty-First Century

THE RISING RISK OF DROUGHT. Droughts of the twenty-first century are characterized by hotter temperatures, longer duration, and greater spatial extent, and are increasingly exacerbated by human demands for water. This situation increases the vulnerability of ecosystems to drought, including a rise in drought-driven tree mortality globally (Allen et al. 2015) and anticipated ecosystem transformations from one state to another—for example, forest to a shrubland (Jiang et al. 2013). When a drought drives changes within ecosystems, there can be a ripple effect through human communities that depend on those ecosystems for critical goods and services (Millar and Stephenson 2015). For example, the “Millennium Drought” (2002–10) in Australia caused unanticipated losses to key services provided by hydrological ecosystems in the Murray–Darling basin—including air quality regulation, waste treatment, erosion prevention, and recreation. The costs of these losses exceeded AUD $800 million, as resources were spent to replace these services and adapt to new drought-impacted ecosystems (Banerjee et al. 2013). Despite the high costs to both nature and people, current drought research, management, and policy perspectives often fail to evaluate how drought affects ecosystems and the “natural capital” they provide to human communities. Integrating these human and natural dimensions of drought is an essential step toward addressing the rising risk of drought in the twenty-first century

Substructure analysis of selected low-richness 2dFGRS clusters of galaxies

Complementary one-, two- and three-dimensional tests for detecting the presence of substructure in clusters of galaxies are applied to recently obtained data from the 2dF Galaxy Redshift Survey. The sample of 25 clusters used in this study includes 16 clusters not previously investigated for substructure. Substructure is detected at or greater than the 99 per cent confidence level in at least one test for 21 of the 25 clusters studied here. From the results, it appears that low-richness clusters commonly contain subclusters participating in mergers. About half of the clusters have two or more components within 0.5 h−1 Mpc of the cluster centroid, and at least three clusters (Abell 1139, Abell 1663 and Abell S333) exhibit velocity-position characteristics consistent with the presence of possible cluster rotation, shear, or infall dynamics. The geometry of certain features is consistent with influence by the host supercluster environments. In general, our results support the hypothesis that low-richness clusters relax to structureless equilibrium states on very long dynamical time-scales (if at all

The 2dF Galaxy Redshift Survey: power-spectrum analysis of the final data set and cosmological implications

We present a power-spectrum analysis of the final 2dF Galaxy Redshift Survey (2dFGRS), employing a direct Fourier method. The sample used comprises 221 414 galaxies with measured redshifts. We investigate in detail the modelling of the sample selection, improving on previous treatments in a number of respects. A new angular mask is derived, based on revisions to the photometric calibration. The redshift selection function is determined by dividing the survey according to rest-frame colour, and deducing a self-consistent treatment of k-corrections and evolution for each population. The covariance matrix for the power-spectrum estimates is determined using two different approaches to the construction of mock surveys, which are used to demonstrate that the input cosmological model can be correctly recovered. We discuss in detail the possible differences between the galaxy and mass power spectra, and treat these using simulations, analytic models and a hybrid empirical approach. Based on these investigations, we are confident that the 2dFGRS power spectrum can be used to infer the matter content of the universe. On large scales, our estimated power spectrum shows evidence for the ‘baryon oscillations' that are predicted in cold dark matter (CDM) models. Fitting to a CDM model, assuming a primordial ns= 1 spectrum, h= 0.72 and negligible neutrino mass, the preferred parameters are Ωmh= 0.168 ± 0.016 and a baryon fraction Ωb/Ωm= 0.185 ± 0.046 (1σ errors). The value of Ωmh is 1σ lower than the 0.20 ± 0.03 in our 2001 analysis of the partially complete 2dFGRS. This shift is largely due to the signal from the newly sampled regions of space, rather than the refinements in the treatment of observational selection. This analysis therefore implies a density significantly below the standard Ωm= 0.3: in combination with cosmic microwave background (CMB) data from the Wilkinson Microwave Anisotropy Probe (WMAP), we infer Ωm= 0.231 ± 0.02

The 2dF Galaxy Redshift Survey: the blue galaxy fraction and implications for the Butcher—Oemler effect

We derive the fraction of blue galaxies in a sample of clusters at z < 0.11 and the general field at the same redshift. The value of the blue fraction is observed to depend on the luminosity limit adopted, cluster-centric radius and, more generally, local galaxy density, but it does not depend on cluster properties. Changes in the blue fraction are due to variations in the relative proportions of red and blue galaxies but the star formation rate for these two galaxy groups remains unchanged. Our results are most consistent with a model where the star formation rate declines rapidly and the blue galaxies tend to be dwarfs and do not favour mechanisms where the Butcher-Oemler effect is caused by processes specific to the cluster environmen

The state of the Martian climate

60°N was +2.0°C, relative to the 1981–2010 average value (Fig. 5.1). This marks a new high for the record. The average annual surface air temperature (SAT) anomaly for 2016 for land stations north of starting in 1900, and is a significant increase over the previous highest value of +1.2°C, which was observed in 2007, 2011, and 2015. Average global annual temperatures also showed record values in 2015 and 2016. Currently, the Arctic is warming at more than twice the rate of lower latitudes

Galaxy ecology: groups and low-density environments in the SDSS and 2dFGRS

We analyse the observed correlation between galaxy environment and Hα emission-line strength, using volume-limited samples and group catalogues of 24 968 galaxies at 0.05 < z < 0.095, drawn from the 2dF Galaxy Redshift Survey ( < −19.5) and the Sloan Digital Sky Survey (Mr < −20.6). We characterize the environment by: (1) Σ5, the surface number density of galaxies determined by the projected distance to the fifth nearest neighbour; and (2) ρ1.1 and ρ5.5, three-dimensional density estimates obtained by convolving the galaxy distribution with Gaussian kernels of dispersion 1.1 and 5.5 Mpc, respectively. We find that star-forming and quiescent galaxies form two distinct populations, as characterized by their Hα equivalent width, W0(Hα). The relative numbers of star-forming and quiescent galaxies vary strongly and continuously with local density. However, the distribution of W0(Hα) amongst the star-forming population is independent of environment. The fraction of star-forming galaxies shows strong sensitivity to the density on large scales, ρ5.5, which is likely independent of the trend with local density, ρ1.1. We use two differently selected group catalogues to demonstrate that the correlation with galaxy density is approximately independent of group velocity dispersion, for σ= 200-1000 km s-1. Even in the lowest-density environments, no more than ∼70 per cent of galaxies show significant Hα emission. Based on these results, we conclude that the present-day correlation between star formation rate and environment is a result of short-time-scale mechanisms that take place preferentially at high redshift, such as starbursts induced by galaxy-galaxy interaction